Most types of pain in the lower back can be treated without any surgery. In fact, in non indicated cases, surgery often does not resolve the pain; studies suggest that almost 20 to 40 percent of surgeries of the back are not successful to relieve the pain. This failure to correctly diagnose and prevent inadvertent surgery is so common that a medical term is coined for it: Failed back surgery syndrome.
Nonetheless, at times back surgery is a very viable option or necessary to treat serious musculoskeletal injuries, nerve compression or neurogenic claudication. Surgery should be considered only after exhausting all other options. Urgent surgery should be considered only in the case of Cauda Equina, impending Cauda Equina or post-traumatic unstable spine or paralysis or weakness in the limbs
When should I consider back surgery?
The following conditions can be considered for surgical treatment:
Herniated or ruptured disks which are compressing the nerves and severe pain is radiating to the legs. Disks are cushion like materials alternating between the bones of the spine and act like shock-absorbers
Spinal stenosis or narrowing of the spinal canal causing significant pain and limitation in walking distance due to pressure on the spinal cord and nerves
Spondylolisthesis is instability of the spine resulting in one or more bones in the spine slip over the other
Vertebral fractures caused by trauma to the bones in the spine or by osteoporosis
Degenerative disk disease or arthritis, or other form of damage to spinal disks as a person gets older
Occasionally,a tumor, an infection, or a nerve root problem like cauda equina syndrome is found as a cause of back pain. In these cases, surgery is advised right away to resolve the pain and prevent complications.
What are some types of back surgery?
There are multiple types of surgeries for back pain which is listed below. But clarity is still not there as to which procedures work best for any particular conditions.
Vertebroplasty and kyphoplasty. These procedures are used to treat compression fractures of the vertebrae caused usually by osteoporosis. These procedures include injecting a glue-like bone cement which hardens in a few minutes and strengthens the bone.
Spinal laminectomy/spinal decompression. This is done to treat spinal stenosis causing narrowing of the spinal canal that results in pain, numbness or weakness in the limbs. The surgeon removes the bone walls from around the spinal cord and any bone spurs. This opens the spinal column to remove pressure on the nerves and the roots.
Discectomy. This removes the offending part of the disk which has herniated and compresses a nerve root or the spinal cord. Laminectomy and discectomy are frequently done together to achieve an optimal result.
Foraminotomy. In this procedure, the surgeon enlarges the bony canal where a nerve root exits the spinal canal and provides larger space for movement of the vital structures without getting compressed by bulging disks or joints thickened with age from pressing on the nerve.
Nucleoplasty or plasma disk decompression. This surgery uses radiofrequency waves to treat low back pain due to a mildly herniated disk. The surgeon inserts a long needle into the disk under guidance of portable X-ray. A plasma laser device is then connected into the needle and the tip is heated, tissue in a small field around is vaporised in the disk. This reduces the size of the disk and relieves pressure on the nerves.
Spinal fusion. The intervertebral disk between two or more vertebrae is removed by the surgeon. The adjacent bones are then fused using bone grafts or metal implants secured by screws. Spinal fusion usually results in some loss of flexibility in the spine which is partially compensated by the spinal segments below and above it. Spinal fusion usually requires a long recovery period to let the bone grafts to get assimilated and fuse the vertebrae together.
Artificial disk replacement. This is a newer alternative to spinal fusion for the treatment in patients suffering from severely damaged disks. This procedure involves complete removal of the disk material and is replaced by an artificial disk. This helps restore the height and allows for movement between the vertebrae.
Other treatment modalities like intradiscal electrothermal therapy and radiofrequency denervation are not found to have any benefit in the long term.
What are the risks of back surgery?
Surgery to the back or spine carries higher risks due to its proximity to the spinal cord and nerves. The most serious of these are a rare possibility of paralysis and infections.
Even with a successful surgery, at times recovery can take a long time. Sometimes healing and complete recovery can take months depending on the type of surgery performed and your condition prior to the surgery. Surgery may cause some loss of flexibility permanently.
What type of anaesthesia is delivered during surgery?
Back surgery is almost always done under general anesthesia. Along with the usual risks of drug reaction, high sensitivity of the body associated with anesthesia, there are risks due to the patient lying face down on the surgical table.
Lying face down or in a prone position changes the flow of blood through the body. This position also limits the anaesthesia team’s access to the patient’s airway. This needs extreme care in the positioning of equipment and monitoring of the patient.
How do I manage pain during my recovery?
Back surgery if not managed correctly often leads to significant pain in post-operative period. You can consider a number of options for pain relief prescribed by the doctor in the days after surgery. These options can be considered after discussion with a pain management specialist to explain the pros and cons including effectiveness, side effects, addiction and recovery process.
Some factors to consider:
Many of your options will involve medications which may be opioids, non-steroidal anti-inflammatory drugs, corticosteroids and local anesthetics. Sometimes a combination of more than one drug will be taken. Multimodal therapies can improve pain control and limit opioid use.
Opioids use should be with care to prevent addiction and other side effects.
Alternative or complementary methods for pain relief which doesn’t include medicines must also be considered.
Many hospitals have a dedicated pain management team which include physician anesthesiologists who specialize in pain management can be important both before and after surgery to develop a tailored plan for your condition and preferences. They consult, and adjust your pain medications, based on the intensity of pain you are experiencing.
Back pain is one of the commonest reasons for absence from work. And it is also the commonest reason to seek medical treatment. It can be uncomfortable, debilitating or disabling.
Back pain can result from injury, extraneous activity or some medical conditions. Back pain affects people of any age, for a variety of reasons. With increasing age, the chance of developing back pain increases, especially in the lower back. This can be due to various factors such as previous work and degenerative changes in spine or any disease.
Lower back pain is commonly linked to the bones in the lumbar spine or the discs between the vertebrae but can also be due to ligaments around the spine and discs, spinal cord and nerves, the lower back muscles, internal organs in the abdomen and pelvis, or the skin around the lumbar area.
Pain in the upper back is usually more sinister and may be due to the disorders of the large blood vessels aorta or vena cava, tumors in the chest, lungs and or the spine.
Causesback pain
Problems with the spine such as osteoporosis commonly seen in the elderly can lead to back pain.
The human or mammalian back is made of a complex structure of muscles, ligaments, tendons, intervertebral discs, and bones, which form a framework together to support the body and enable us to dynamize our movements.
The individual bones of the spine are cushioned alternatively with soft cartilage-like shock-absorbing pads called disks.
Problems with any of these constituents can cause back pain. Still in some cases, the cause of back pain remains unclear.
Damage to spine or supporting structures can result from excessive strain, medical conditions, poor posture and other unknown causes.
Strain
Back pain commonly results from excessive strain, tension, or injury. Common causes of back pain are:
overstrained muscles or ligaments
a paraspinal muscle spasm
muscle tension
damaged or degenerated disks
Injuries or fractures
Activities causing strains or spasms include:
lifting things improperly
lifting too heavy things
abrupt and awkward movements of the back
Structural problems
A number of structural problems in or around the spine can result in back pain.
Ruptured disks: Vertebrae in the spine is cushioned by disks on both top and bottom. If one of these disks ruptures, it bulges out and puts pressure on a nerve, resulting in back pain that can radiate to the limbs.
Bulging disks: Similar to ruptured disks, a bulging disk can cause more of a back pain but is less likely to have radiating pain in the limbs.
Sciatica: common term for sharp and shooting pain from the buttock and down the back of the leg, caused by pressure on the nerves in the spinal canal.
Arthritis: Osteoarthritis or degeneration of any of the three joints between two vertebrae can cause pain in the hips, lower back, and other places.
Lumbar canal stenosis: The space around the spinal cord narrows due to thickening of the ligaments. This is known as spinal stenosis.
Abnormal curvature of the spine: Any change in the normal curves of the spine changes the mechanics and weight transmission, back pain can result. Scoliosis is one such condition, in which the spine curves and rotates to the side.
Osteoporosis: With aging bones, including the vertebrae of the spine, become porous, less denser and brittle, causing compression fractures even with minor injury or even body weight.
Kidney problems: Stones, infection or other disorders of kidney can cause back pain.
Movement and posture
Most of us use a desk for our work, especially while using a computer. Invariably we tend to get into a slouched or hunched posture for a long time. This is usually a cause for upper back and shoulder pain among the urban population or white collar workers.
Back pain also results from few day to day activities or poor posture.
Examples include:
Overzealous twisting
coughing or sneezing
muscle tension or strain
over-stretching
bending awkwardly or suddenly
pushing, pulling, lifting, or carrying out heavy manual activity
standing or sitting for long periods in same posture
straining the neck forward
long driving without a break
sleeping on an uncomfortable bed or position
Other causes
Some medical conditions can lead to back pain.
Cauda equina syndrome: The cauda equina is the bundle of spinal nerve roots coming out of the lower end of the spinal cord. Symptoms can vary from a dull pain in the lower back and upper buttocks to numbness in the buttocks, genitalia, and thighs along with loss of bowel(defecation) and bladder(micturition) control.
Cancer of the spine: A tumor in the spine arising from any structure can give rise to pressure symptoms and destruction of nearby tissues. All this can manifest as back pain.
Infections of the spine: Tuberculosis of the spine is a common condition seen in the 3rd world population. Apart from back pain fever is another common symptom.
Other infections: Inflammatory disease in the pelvis, infections of the bladder, or kidney may also lead to back pain.
Sleep disorders: In studies, it has been noticed that individuals with sleep disorders are more likely to experience back pain.
Shingles: Infection of the nervous system may lead to back pain.
Risk factors for back pain
Studies over the years have found the following associated factors for developing low back pain:
occupational activities
pregnancy
a sedentary lifestyle
poor physical fitness
older age
obesity and excess weight
smoking
strenuous physical exercise or work, especially if done incorrectly or without proper stretching or warmup
genetic factors
medical conditions, like arthritis and cancer
Lower back pain is also seen more commonly in women than in men, probably due to hormonal factors. Stress, anxiety, and mood disorders along with other psychological conditions have also been linked to back pain.
Symptoms of the back pain
Back pain is the commonest symptom in spinal problems which at times may shoot down all the way to the buttocks and legs.
Some back problems can cause pain in other parts of the body, depending on which nerves are affected.
The pain is usually temporary and often goes away with rest, but if it recurs or is associated with any of the following, you must visit a doctor:
weight loss
fever
inflammation or swelling on the back
persistent back pain, where lying down or resting does not help
pain down along the legs
pain that radiating below the knees
Pain due to recent injury, blow or trauma to the back
urinary incontinence or other disturbance
fecal incontinence, or loss of control over defecation
numbness around the genitals
numbness around the anus
numbness around the buttocks
When to see a doctor
You should seek medical care if you experience numbness or tingling, or if the back pain:
that is not relieved with rest
Caused due to an injury or fall
with numbness in the legs
With numbness in saddle area
with weakness in legs
with fever
with significant weight loss
Diagnosis
Your doctor will be able to diagnose your back pain with few questions about symptoms and a physical examination.
Few imaging scan and other tests may be done to confirm if:
back pain is a result from an injury
there is some underlying cause for the pain
the pain persists for a long period
An X-ray, MRI, or CT scan can help confirm the diagnosis by giving visual information about the state of the tissues in the back.
X-rays help see the alignment of the bones and find signs of arthritis or bones, but they can’t reveal damage in the soft tissues like muscles, spinal cord, nerves, or intervertebral disks.
MRI or CT scans give spatial visualisation of herniated disks or problems with other tissues such as tendons, nerves, ligaments, blood vessels, muscles, and bones as well.
Bone scans pick up even very early changes in bone and can detect bone tumors or subtle compression fractures due to osteoporosis. A radioactive substance or also called a tracer is injected into a vein. The tracer gets concentrated in the high activity areas in bones, which is then visualised with the aid of a special camera.
Electromyography or EMG measures the conduction of electrical impulses. This can help confirm nerve compression, due to a herniated disk or spinal stenosis or any other cause.
Your doctor may also advise a blood test if the infection is suspected.
Chronic or acute back pain?
Back pain is for management purpose categorized into two types:
Acute back pain is a sudden abrupt start of the pain and may last for up to 6 weeks.
Chronic or long-term pain develops gradually over a longer period, lasts for months, with or without waxing and waning phases and causes ongoing problems.
Some people have both occasional bouts of intense pain with intervening periods of fairly continuous mild back pain. This Makes it difficult for a doctor to ascertain or categorize the pain as acute or chronic back pain.
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